Organization
WONDER YEARS PCH
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. ANGELA B TILLMAN (OWNER)
(773) 354-3040
Entity
Organization
Contact information
Practice address
3321 OLD SALEM RD SE, CONYERS, GA 30013-2224
(770) 860-1320
Mailing address
3321 OLD SALEM RD SE, CONYERS, GA 30013-2224
(770) 860-1320
Taxonomy
Speciality
Code
Description
License number
State
251C00000X
Developmentally Disabled Services Day Training Agency
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
124269217A
—
GA
Enumeration date
04/12/2010
Last updated
04/12/2010
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